Screen Chronic Pain Patients for Depression, Sleep Disorders, Suicidal Ideation

Chronic pain frequently is associated with suicide ideation, according to behavioral psychologist Martin D. Cheatle, PhD, Clinical Associate Professor of Psychology in Psychiatry at the University of Pennsylvania in Philadelphia.

Possible mediators of the relationship between pain and suicide risk include insomnia, depression, family history of suicide, substance use disorder, poor stress-coping abilities, and catastrophizing.

Clinics should have action plans for interventions for patients identified as being actively suicidal or at high-risk for suicide, said Dr. Cheatle, Director of Behavioral Medicine at the Penn Pain Medicine Center in Philadelphia. 

During his presentation titled “Living On the Edge: Pain, Suicide, and Depression,” Dr. Cheatle cited various studies linking chronic pain with suicide ideation. In a study of 113 chronic pain patients published in Pain Practice in 2012, researchers found that perceived burdensomeness was the sole predictor of suicidal ideation. Researchers who studied 51 patients with non-cancer chronic pain found that 24% of them reported suicidal ideation and endorsed higher levels of sleep-onset insomnia, pain intensity, medication usage, pain-related interference, and depressive symptoms, according to a paper published in 2004 in the Clinical Journal of Pain. A study of 1512 chronic pain patients found that 32% of subjects reported some form of suicidal ideation, with results showing that two predictors of the presence and severity of suicidal ideation were the magnitude of depressive symptoms and the degree of pain-related catastrophizing, researchers reported in 2006 in Pain.

“I think people get into the cycle of developing pain, having a mood disorder, developing a sleep disorder, and it just feeds on itself,” Dr. Cheatle said, adding that all three problems must be tackled aggressively at the same time to control patients' chronic pain.

Behaviors suggestive of an increased risk of suicide include giving away personal property, lack of future goals, making a will, and experiencing recent loss, he said. The lack of future goals is a particularly telling sign, Dr. Cheatle said. He noted that urine drug screens also have a role in risk assessment. If a patient has been prescribed opioids or benzodiazepines, but the drugs do not show up in urine drug tests, the patient may be hoarding the medications. They may be hoarding because they do not trust that their physician will prescribe more pain medication or they be saving up the drugs to kill themselves when their circumstances get worse.

Dr. Cheatle noted that a biopsychosocial approach to pain has been shown to improve treatment outcomes significantly. This approach has five main components: cognitive behavioral therapy (CBT), exercise, nutrition (eg, weight control), evidence-based rational pharmacotherapy, and social support. The objective of CBT is to guide patients in recognizing and reconceptualizing their personal view of pain, identifying their role in the healing process, and getting the patient to be proactive. CBT has been found to be effective in treating the chronic pain associated with a number of disorders, including arthritis, lupus, and low back pain.